THE FUTURE OF HEALTH – HEALTH OF THE FUTURE
Fourth European Consultation on Future Trends
– HEALTH OF THE FUTURE
Fourth European Consultation on Future Trends
Keith Barnard (editor)
Preface by John Wyn Owen CB
Europe and anticipated future problems and opportunities. A point of departure was provided by the results of a study carried out by the University of Cambridge entitled “Policy futures for UK health”. The participants included those involved in the study and other aspects of the Nuffield Trust’s programme, those who had participated in the preparation of HEALTH21, and others with international experience and expertise.
The importance of evidence and research and the usefulness of scenarios were reaffirmed. Attention was drawn to the limited “life” of futures studies, based as they are on assumptions that are constantly changing. Experience has proved the usefulness of periodically bringing together people from different sectors and different walks of life to discuss futures. Further periodic consultations would be a valuable tool in the continuing process of monitoring, review and revision to ensure that WHO’s European policy framework remains relevant for the Region as a whole. The Regional Office should continue its policy dialogues with country partners and others, and its collaboration with the Nuffield Trust in the use of futures in the creation and implementation of health policy.
This document has been edited by Keith Barnard.
ISBN 1-902089-89-8
© World Health Organization
The views expressed in this publication are those of the contributors and do not necessarily represent the decisions or the stated policy of the World Health Organization.
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Foreword . . . iv
Preface . . . v
Introduction . . . 1
An explanation . . . 5
PART I: THE DIALOGUE . . . 7-88 Using futures in the policy process . . . 7
Background. . . 7
The work of the Nuffield Trust . . . 8
The British government Foresight programme. . . 12
Futures in the Department of Health. . . 16
HEALTH21 – a future-oriented policy framework for Europe . . . 17
The Nuffield Trust “Policy futures for UK health” project . . . 23
International dimensions of the Nuffield Trust project . . . 30
Key Issues for Europe. . . 39
The future of Europe in the light of geopolitical and economic developments . . . 39
People, alliances and partnerships in the future Europe . . . 47
The future of work and health in Europe . . . 52
Equal opportunity in a future Europe . . . 57
Further reflections . . . 61
Preparing for Change/Implementing HEALTH21. . . 65
Building on the past: lessons from the Americas . . . 65
Lessons from Wales. . . 69
Looking forward: combining clinical and public health knowledge . . . 74
Using research and evidence in moving ahead. . . 77
Further reflections . . . 82
The emerging picture . . . 85
Continuing collaboration . . . 87
PART II: THE CONTEXT. . . 89-185 The International Context . . . 89
HEALTH21 as a future-oriented policy framework for Europe. . . 89
The use of “futures” in European health for all policy development . . . 97
Experience from the Americas. . . 124
The United Kingdom Context. . . 133
Nuffield Trust/Judge Institute project on health policy futures . . . 133
Virtual reorganisation by design: an approach to progressing the public’s health in Wales . 138 Linking the United Kingdom and International Contexts. . . 153
A Scenario for Health and Care in the Europe Union of 2020 . . . 153
Responding to the Nuffield Trust/Judge Institute project on health policy futures: reflections in a WHO perspective . . . 175
List of Participants. . . 187
The WHO Constitution lays down the objective to promote the highest attainable level of health for all people. Efforts made by and within its Member States are vital tools for WHO to fulfil this objective. The WHO Regional Office for Europe, therefore, highly values the work of the Nuffield Trust both in the United Kingdom, and on the European scale.
The Nuffield Trust pioneers work and provides excellence in many fields of public health in which WHO shares common interests. It promotes independent analysis and informed debate about health policy in the United Kingdom. The Nuffield Trust thereby generates important lessons and reviews options that enable people to enjoy better health, and receive quality and effective health care in the United Kingdom and elsewhere in the WHO European Region. It acts as pathfinder for policies, and acquires experience in their feasibility, affordability and acceptability within a national context. WHO can build on this experience and I, therefore, look forward to our continued collaboration with the Nuffield Trust.
I am particularly grateful to the Nuffield Trust for sharing their work on health futures with us. This volume makes a fundamental contribution to ensuring that health policy translates into practical action to shape the future of health, and the health of the future in the WHO European Region.
Our WHO goal of seeking health for all may be timeless, but the world in which we pursue that goal is changing. We need to be constantly tracking the trends, pressures and innovations that will influence positively, or negatively, our efforts to protect and promote health.
Forecasting the repercussions that political, social and technical change will have on health, exerting influence over them, and taking decisions now, to make them as favourable or harmless as possible, are onerous tasks for health decision-makers.
This volume summarises a consultation held by the Nuffield Trust and the WHO Regional Office. It explores the future environment of health in Europe, and anticipates future problems and opportunities. It benefits greatly from the Nuffield Trust’s own study “Policy futures for UK health”. The Nuffield Trust’s achievement is impressive in scanning the future environment of health, in identifying the implications for policy and action, and in distilling the findings succinctly in a form to which decision-makers can respond. It has inspired the WHO Regional Office in its work. I am sure this example will also stimulate colleagues in other countries to undertake their own futures studies to help their policy-makers find sustainable means to improve the health, and quality of life, of the peoples of Europe.
Marc Danzon, M.D.
Regional Director WHO Regional Office for Europe May 2003
Since its inception, the Nuffield Trust has identified individuals and subjects that would have an impact on health and health care policy in the United Kingdom. The hallmark of the Trust is its tradition of independence. Its main aim has been to provide opportunities for the exchange and discussion of new ideas, new knowledge or simply insights, with the intention of contributing to the medium- and long-term health policy agenda. Our project “Policy futures for UK health” analyses the broad environment for health in the United Kingdom in the year 2015, and the implications of that for current health policy. It indicates areas where the government could take action now to anticipate the likely circumstances in 2015.
This time-frame was chosen carefully, with a view to making a constructive contribution to policy development. It was emphatically not to be a piece of abstract futurology. The period under review extends beyond the usual constraints of the electoral cycle, but is short enough to allow a realistic assessment of future developments. The Nuffield Trust wants to stimulate change in the culture of the health policy-making process and to encourage thinking and analysis based on evidence. It is important that the debate is conducted as widely as possible, not only by politicians but also by others outside the political forum who share the wish to improve health. The policy futures exercise does not focus narrowly on curative interventions but considers more widely the factors that determine health and quality of life, albeit taking care to anchor these to the realities of policy-making and resource constraints. Policy futures provide material to justify considering important elements that could be overlooked in the context of maintaining health and wellbeing and that require cross--departmental working.
Also, health increasingly has European and wider international dimensions. Good health is, after all, good economics. Giving health priority and a wider focus beyond health services will bring dividends.
The Nuffield Trust values highly the opportunity of working with the WHO Regional Office for Europe to ensure that the programme of work that it supports is alert to the latest policy thinking and policy analysis.
John Coles, in his book Making foreign policy, says, “Policy-making is hard. It needs
intellectual rigour, a capacity for innovation, a grasp of political reality, a sense of the future and, quite often, a certain courage”. He advocates planning and futures work, saying, “the purpose is not to predict confidently what will happen in the world – a task for which there is little science – but by concentrating minds on alternative scenarios and possible developments to make today’s decisions sounder and more likely to stand the test of time”. There is much included in this publication to inform those who have health policy and operational
responsibilities.
The Nuffield Trust and the WHO Regional Office for Europe hope that this publication contributes to the wider health debate and strengthens both national and international capacity to achieve health gain.
John Wyn Owen, CB Secretary, Nuffield Trust
June 2003
The Fourth European Consultation on Future Trends, hosted by the Nuffield Trust, was convened to consider prospects for the implementation of the HEALTH21 policy framework adopted by the WHO Regional Committee for Europe in September 1998, to explore the future environment of health in Europe, and to anticipate future problems and opportunities.
A point of departure was provided by a study commissioned by the Nuffield Trust and carried out by the Judge Institute at the University of Cambridge entitled “Policy futures for UK health”. This is complemented by the United Kingdom government’s multisectoral Foresight initiative, an explicit use of futures thinking as an input into policy-making across the board.
Using futures in the policy process
The Third Consultation on Future Trends and the European HFA Strategy1 provided a direct input into the drafting of the HEALTH21 policy framework. Now the stress is on the place of futures in developing an effective and sustained implementation of HEALTH21.
It is important that policy-makers are enabled not only to respond to present circumstances but to prepare for conceivable future situations (plausible, desirable or potentially
catastrophic) that will have consequences for population health and the provision of services.
It is in this spirit that the Nuffield Trust’s futures programme is intended as a contribution to the United Kingdom’s health policy process. The “Policy futures for UK health” project has produced an overview report, Pathfinder, that presents a distillation of themes and issues and a policy assessment, i.e. what should inform United Kingdom health policy as we move forward
1.Third Consultation on Future Trends and the European HFA Strategy. Report on a meeting, Bratislava, Slovak Republic, 26–27 October 1995. Copenhagen, WHO Regional Office for Europe, 1996 (document EUR/ICP/EHFA 94 01/MT01).
to 2015 and what are the gaps in health policy now. Pathfinderhas focused on the following six issues, which provide a synthesis of the health agenda.
People’s expectations and financial sustainability.Expectations – both about health and about the services provided – are rising, and need to be recognised and managed. This requires looking specifically at the long-term sustainability of the present health service.
Demography and aging. In terms of overall population structure, the United Kingdom will have an aging population and a smaller working population. There is a need for an integrated policy for older people, and also a reorientation of policy that takes proper account of the individual experience of older people.
Information and knowledge management. An effective strategy would offer many potential benefits in policy-making, training health professionals and communication of public policy. It should have an international focus.
Scientific advances and new technology. New knowledge, increasing technical expertise and increasing therapeutic potential all have consequences (e.g. shifts in location of care, greater use of machines and technology) exposing underlying tensions in health policy. Major issues of planning and management, e.g. in changing the location of care, need to be addressed.
Workforce education and training.The increasing pressures on health professionals and shifting roles highlight the importance of continuous education and training, and the need to reassess current workforce planning.
System performance and quality (efficiency, effectiveness, economy and equity).Questions on the overall performance of the health system point to the value of international comparisons and benchmarking, and the need for developing and improving outcome measures.
The purpose of Pathfinderwas not to make predictions but to try and discover how policy- making and planning might benefit from a forward perspective. As an “agenda for health”, the findings of the project make clear that innovative, long-term strategic thinking will be needed to deal with the pressing issues.
There are both similarities and differences between the “Policy futures for UK health” project and HEALTH21, and these were noted during the Consultation. More importantly, the project was commended as a model, especially in terms of its comprehensiveness and links with policy-making realities. It was hoped that other countries might follow it as part of their implementation of HEALTH21.
Key issues for Europe
The second part of the Consultation focused on the prospects in the Region for implementing HEALTH21. In the structuring of the meeting a number of issues had been identified as factors that could facilitate or impede the ability of WHO and Member States to implement policies and establish structures and services to improve the health of their peoples.
Analysis of geopolitical and economic developments raises questions as to the ability of the international community to create partnerships and collaborative arrangements that generate mutual benefits – whether countries and European organisations can exercise any influence on
geopolitical developments and the working of the economy at the global level. As the implications of globalisation become clearer, there is concern over the ability of individual countries, subnational levels of government and non-governmental organisations (NGOs) to pursue their economic and social development agendas for the benefit of their electorates and constituencies.
HEALTH21 emphasises that the achievement of its objectives will depend on effective alliances and partnerships in, as well as between, countries. The policy calls for a strategy to mobilise new partners for health: who these partners should be and how health sector actors should go about engaging with them; and what new networks, agendas and relationships should public health agencies at various levels establish and sustain.
There are also questions as to how ordinary people’s own resources could be harnessed to improve their own and their communities’ health; as to what kinds of relationships will or should evolve between individuals as citizens and as users of services and the political decision-makers and professional providers; and as to whether developments in information technology can close the information gap and the imbalance of resources. What will be the relationship in future between information, evidence and judgement?
Developments in different technologies and in the structures of the economy have serious implications for the future of work and health in Europe: the kinds of workplaces there would be and the nature of the hazards to the health of those working there. There is a range of expected health problems – physical, social and psychological – for which policy responses are needed. As to demographic factors, the shrinking and ageing workforce, for example, will be expected to cover the social costs of caring for the elderly and other dependent groups.
There are the challenges of ensuring meaningful employment opportunities for young workers so that they can lead satisfying lives, and of harnessing the strengths of older workers. Can inter-generational solidarity and equity be sustained in the face of accelerating technological change, with its likely consequences of de-skilling and structural unemployment?
Lastly, what are the prospects for equity in health in a future Europe – for giving people equal opportunity to enjoy good health and lead satisfying lives? If the language of equity is coming back into currency again, then in a WHO perspective this is welcome because such values have always been at the heart of the Organisation’s policy-making. It is essential to understand the underlying trends in the macro-environment, in terms both of the impact on the main political forces in society and the distribution of power and of the way they affect people’s ability to lead their own lives. It then becomes possible to identify policy options as responses to these trends, and to set up institutional and other arrangements to support a strategy to promote equity across social groups, generations and genders.
Implementing H
EALTH21
The final phase of the Consultation first looked at practical experience to bear in mind in implementing HEALTH21. Two thematic issues were then addressed. The first, combining clinical and public health knowledge to support health protection and promotion, reflects a key message of HEALTH21 – the need to “break down the barriers” between the curative services of clinical medicine and the broad field of other health work usually referred to as
“public health”.
The second thematic issue – using research and evidence in looking ahead – responds to the recurring theme in HEALTH21 that policies, service development and professional practice should all be built on the strongest possible knowledge foundations. The environment for policy implementation in countries is never static. Continuous monitoring is needed to compare policy in action with the original policy intent, and to assess the implications of any divergence. Foresight and continuous monitoring can be used to detect weak signals
portending change in the operating environment. A judgement may then be made on whether there is a need to develop scenarios of possible new futures.
Conclusions
The emerging sense of the Consultation was that the future environment for health would indeed be complex, volatile and stressful for policy-makers and for those responsible for policy implementation. Some mechanism for continuous scanning of the future is now imperative.
We now have ample evidence of the importance of people from different sectors and different walks of life periodically coming together to discuss futures, such as the consultation in 1998 on food and agriculture2. The outcomes of such discussions can be used as an important input to policy-making and planning.
In a WHO perspective, futures consultations continue to be a valuable tool in ensuring that the health for all policy framework, adapted and implemented according to the needs of particular countries and communities, remains valid for the Region as a whole. Consultations help generate the intelligence needed to prepare realistically for possible futures and to craft rational, rapid responses to developments in the Region as they occur.
The Consultation generally endorsed the intention of the Regional Office to continue dialogue with relevant partners. Opportunities for further Nuffield Trust/WHO collaboration in the use of futures for health policy-making and implementation would be explored.
2.Food and agriculture aspects of the draft health policy for the European Region. Report on a WHO consultation, Copenhagen, 9–10 March 1998.Copenhagen, WHO Regional Office for Europe, 1998 (document EUR/ICP/EXCC 01 03 01(A)).
The material presented in this volume is set out in two parts, with two purposes. The first purpose is to recapture the spirit of the meeting held in London in December 1999, which had been stimulated by recent significant developments in the macro-environment for health. Most notably there was the Seattle meeting of the World Trade Organisation, and all that the events there seemed to imply when set against other discernable trends.
Seattle made us very conscious of the political and economic implications of globalisation and the impact on countries and communities. We were starkly reminded of the relationship between health and development: the contribution of improved population health to development and the effect of equitable economic development in improving population health.
In the United Kingdom, there were renewed hopes for a real peace in Northern Ireland, reminding participants that peace had long been seen by WHO as a prerequisite for health.
Part Iis an account of the meeting. It reconstructs the presentations made by the invited experts, who brought the insights of their different professional backgrounds and experience to bear on the issues, and the dialogue between participants that their presentations
generated. The presenters were all invited to review the first transcription of the proceedings and, if they so wished, to revise their contributions so that they properly reflected the intended messages.
The second purpose, addressed in Part II, is to present the context of the dialogue. Selected papers drawn from those prepared for or used by the meeting, which set out one dimension or other of the context, are reproduced. It will be recognised that – quite consciously – we were dealing with two related contexts.
The first was the international context provided by WHO’s health policy and its evolution from the original “health for all” resolution of the World Health Assembly in 1977 to the adoption by the Health Assembly and the Regional Committee for Europe in 1998 of a renewal of the policy to take us forward in a new century.
The European context is conveyed in Part II by an interpretative account by Herbert Zöllner of the preparation of HEALTH21, the policy document adopted in 1998; and by a background paper by Keith Barnard on the experience of using “futures” in WHO health for all policy development. A point of international comparison is offered through a companion paper dealing with developments in the WHO Region of the Americas prepared by Cristina Puentes- Markides, a staff member of the WHO Regional Office for the Americas participating in the Consultation.
The second context is the United Kingdom, a context now made richer and more complex by the devolution of powers in matters of domestic policy, including health, from central
government in London to a Scottish Parliament and to Assemblies in Wales and Northern Ireland. Each of these three constituent parts of the United Kingdom now has its own Executive, with Ministers and their departments accountable to the parliamentary body. The United Kingdom government retains responsibility for all countrywide functions and policies not covered by the legislation on devolution, as well as continuing responsibility for domestic policy in England.
The United Kingdom context, and a speculation on trends and the implications for government policy and the need for action, is the concern of the “Policy futures for UK health” project. The executive summary of the project is reproduced here. This
multidimensional policy-oriented scan is complemented by an account of developments and prospects in Wales by Morton Warner. This highlights the possibilities of re-thinking current approaches to health policy-making and action by focusing on a particular geographical and political context.
Finally, linking these two contexts together, the Nuffield Trust perception of trends and possibilities in Europe is provided in a paper from Graham Lister. Reflections by Keith
Barnard, from a WHO perspective, on the “Policy futures for UK health” project conclude Part II.
USING FUTURES IN THE POLICY PROCESS
Background
John Wyn Owen
Herbert Zöllner will brief us on the purpose and objectives of the meeting, but first let me say on behalf of the Trustees how delighted we are to be able to work with WHO on health futures.
Herbert Zöllner
Thank you very much; it is a great pleasure to be here. Health futures is not strange to WHO, this being our fourth European consultation. I think I should start with a word on the genesis of this particular meeting. About a year ago we had a visit to the Regional Office in
Copenhagen from John Wyn Owen in his capacity as Secretary to the Nuffield Trust. During this visit we discovered a meeting of minds on the need for futures studies, which we see as an essential input to policy development, and we saw an opportunity for building on existing efforts.
The Nuffield Trust futures team has embarked on a national endeavour to look into the future of the health care system and society as a whole, and to draw conclusions. As the WHO Secretariat, we need to listen to and learn from our Member States and their experts. In turn we can give the work of the Nuffield Trust the international dimension it has been looking for.
So we are hoping that in this meeting, with the participation of other international experts who can contribute the European and global perspectives, we can build on what the Nuffield Trust has done so far. This should help both our work in the Regional Office and the work done in other Member States.
As Fritz Schumacher said, the future cannot be foreseen – it can only be explored. Taking stock of the future right now is important for WHO, because it allows us to explore the environment in which our policy and strategies will be implemented. It is the next stage
following the preparation of the renewed health for all policy framework of HEALTH21, when we had to look around and ahead to see what the challenges and the opportunities would be.
We looked especially at mega-politics, macroeconomics and social trends to make an assessment of what the policy would need to take into account.
We now have a policy and a framework, which suggests possible strategies. This has been agreed by our Member States, and we now face the challenge of implementing it. In doing so, we come back to a number of the same issues: in what direction society and the economy will move, what the continuing differences between east and west in Europe will be, how the health challenges will be perceived, and so forth. We have put them on the agenda for this meeting as “Key issues for Europe”.
This meeting is part of a continuing or unfolding process in which we both check old insights and understandings and carry forward our scan of the environment. This kind of futures scanning is not something that finishes with one meeting, which is why we have had a sequence of meetings over this past decade. Suppose we had stopped after just one meeting, our first Consultation in Copenhagen in 1990. If, in drafting HEALTH21 in 1998, we had made our assumptions about the future environment based only on what we had perceived in 1990 we would have been quite wrong.
The meeting is nicely patterned. It starts with the place of futures within the policy process.
We need to hear from the Nuffield Trust team how they went about this exercise in the United Kingdom and what the main conclusions were. We will then attempt a commentary on the project – a first set of responses and reflections. Then, tomorrow, we will bring in various international dimensions, and in the concluding session we can reflect on what has emerged and the messages we can take from the meeting.
The work of the Nuffield Trust
John Wyn Owen
I am a health service administrator by background. Each decade in which I have worked has had different characteristics. It was hospitaladministration when I joined the service. In the 1970s it became health servicesadministration, and in the 1980s health service management. I would claim that the 1990s has been the decade of managing for health. And looking beyond 31 December, I think we will be moving into the decade of globalhealth. That perception is also reflected in the work of the Nuffield Trust. We currently have five main themes, one of which is policy futures. Before I come to that I will give you the other four.
The first theme is the changing role of the state and health policy, globalisation and
devolution. Our interest is in trying to raise awareness in the United Kingdom of global issues in health, to ensure that we ourselves play our part as a world resource in health and health care. We have a strong interest in devolution and we have established a standing conference on devolution and health, working collaboratively with the Constitution Unit of University College, London.
The second theme is public health. Unsolicited, we will be offering the United Kingdom government a draft “Health of the people’s bill”, which is our attempt to try and define what a
modern public health act for the United Kingdom would look like. We met in Oxford last year, partly to celebrate the 150th anniversary of the first Public Health Act of 1848 but also to ask ourselves the question: if we were writing instructions for the parliamentary counsel
responsible for drafting legislation, what would we want to see in a modern public health act?
The third theme is quality in health care. This has three component parts. First, there are policy matters relating to quality, and for this we are collaborating with the Commonwealth Fund and RAND. Second, we are taking advantage of the investment in measurement made in the United States, particularly by the team at RAND, to say what happens if you try to apply their work to measure health care in the United Kingdom. The third component has been working with colleagues at the Organisation for Economic Co-operation and Development on explaining to ministers of finance and heads of government what they get for their investment in health care.
The fourth theme is humanities and medicine. In March 1998 we had a conference at Windsor.
We looked at three components: the humanities in medicine, the humanities in medical education and in community development, and the arts as therapies. We were so taken collectively by what happened at the meeting that we issued the “Declaration of Windsor on the Arts, Health and Well-being”.
In September 1999 we held a second Windsor conference, and the communiqué from that announced the establishment of a national Council for Arts and Humanities in Health and Medicine, with a co-ordinating centre at the University of Durham. David Weatherall was the opening speaker at our meeting. He talked about “the art of the practice of the science of medicine”, and we see that as an important way of indicating how the Nuffield Trust’s traditional role might be interpreted in the present and in the future.
So we come to the fifth theme, which is our main interest today: United Kingdom health policy and the place of futures in that context.
The Trust was set up in 1940 as the Nuffield Provincial Hospitals Trust. Since its inception it has identified individuals and subjects that would impact on health and health care policy in the United Kingdom. If we look back over this period of 60 years, we see some very significant milestone events.
Screening in medical carewas an influential publication in the 1960s. Archie Cochrane’s
Effectiveness and efficiency, published by the Trust in 1971, has had a major impact on thinking around the world. Tom McKeown’sThe role of medicine: dream, mirage or nemesis, published in 1976, has also had a lasting impact, and was even referred to in WHO’s latest annual report.
David Weatherall wrote on the new genetics and clinical practice in the early 1980s and, perhaps more controversially, Alain Enthoven responded to the Trustees’ invitation to write a reflective essay on the management on the National Health Service (NHS). We invited him back this last year; he has produced an assessment of what happened to some of his ideas on markets in health care, as well as some recommendations about the future.
One of the hallmarks of the Nuffield Trust is its tradition of independence. Its main aim has been to provide opportunities for the exchange and discussion of ideas, new knowledge and insight. This has had the intention of contributing to the medium- and long-term health and health service policy agenda, thereby enabling the people of the United Kingdom to achieve better levels of health as well as an effective health care service.
Partly in the context of celebrating the 50th anniversary of the NHS in 1998, we funded the NHS Confederation to examine what the next 50 years might entail for the health service.
There was a delphi exercise, a public consultation and a number of community-oriented focus groups. And two scenarios were developed: one was called “find my way”, and the other “trust their guidance”.
When people were polled as to which scenario they thought we would have in the future, the overall balance of opinion was that the future would be one of people finding their way rather than trusting professional guidance. But the general conclusion was that it would be an age of uncertainty and anxiety. This mirrored the headline in the Financial Times last
September, referring to the United Kingdom: “Wealth in 2010 will be marred by a lack of well-being.”
We are not interested in speculation for its own sake, but in analysis with a view to action and in thinking based on evidence. We want to ensure that what is already known contributes to the “cutting edge”, both informing the long-term strategic direction in health policy and improving health care. Adopting the US Institute of Medicine’s maxim, we believe we are a voice of moderation, wisdom and integrity, but above all we are free and beholden to no-one.
And we are delighted that we can have this meeting with like-minded people who can help the Trust maintain that tradition.
Over the years I have been personally involved in a number of health policy futures projects.
When I was at St Thomas’s Hospital in 1974 the then Professor of General Practice, David Morrell, wrote a speculative paper on health in the London Borough of Lambeth in 1984.
Later, at national level in the Welsh Office, the United Kingdom government’s department responsible for Welsh affairs, we commissioned the Welsh Health Planning Forum project
“Health and social care 2010”. This was part of our programme to achieve health gain for the people of Wales. Then in Australia, when I was chairman of the Australian Ministers’ Council, we had a futures project on the Australian health system in 2010.
So it will come as no surprise that, on becoming Secretary of the Nuffield Trust, I argued for policy futures and a medium- to long-term perspective as we developed the Trust’s agenda. I advised the Trustees to establish a Policy Evaluation Advisory Group, supported by the appointment of a Nuffield Trust Fellow at the Judge Institute of Management Studies at the University of Cambridge.
The purpose was to put in place a programme of work to conduct an annual environmental scan and health policy assessment. The particular emphasis was to be on evaluationrather than merely monitoring what was happening, and on taking a futures perspective. It is interesting that when the United Kingdom Parliament’s Comptroller and Auditor General commented on our policy futures document, he said, “All I can do is monitor government policy. I cannot actually evaluate government policy”. So our attempt to push the boundaries is an important contribution in the United Kingdom.
The Policy Evaluation Advisory Group meets about three times a year. It has six members in addition to myself, plus a technical support group. It is multidisciplinary. We took people who were at a formative stage in their careers. This means that they were all busy people, but also that they felt that this investment of their time would be rewarded.
The group’s initial task was to formulate the process for conducting an environmental scan – to develop a methodology. When we considered our first scan we decided that further analysis was needed. Ten technical papers were commissioned, covering a broad range of issues in a futures perspective. And it was reading through these technical papers that enabled us to draft our Pathfinderconsultation document. This is an assessment of the forward look to 2015. It is asking what the policy should be now to take account of the trends and issues, what should inform United Kingdom health policy, and what the gaps in health policy are at the present time.
As Charlotte Dargie will be presenting later, we have identified six issues that need to be addressed in United Kingdom health policy: people’s expectations and financial sustainability;
demography and aging; information and knowledge management; scientific advance and new technology; workforce education and training; and performance and quality. In our report we have the four E’s – efficiency, equity, economy and effectiveness. But I think there should be a fifth – empowerment – to fit in with the notion of people finding their way. That’s a matter for further deliberation.
It was always our intention to produce a prototype health policy futures document in 1999, and this we did by publishing the Pathfinderdocument and the technical papers in September.
The next intention is to publish Health policy futures 2000and an annual full-scale review thereafter. So, in simple process terms, we are on track and on time. We intend in May 2000 to write what will become an annual three-page letter to the British Prime Minister, based on the analysis developed in the policy futures consultation document.
Performance and quality issues provoke questions of how the health services are doing overall.
And that has been the thrust of a number of invitational seminars the Trust has held. I believe that benchmarking the United Kingdom internationally in terms of outcome, health policy interventions and systems performance should be a central part of policy assessment, as well as a driving force for policy development and priorities.
When I was in the Welsh Office, one of the most important insights that we gained was the need to calibrate Wales against Europe. This was not the view of the central departments of government, who believed we should simply benchmark Wales against other parts of the United Kingdom. So it was not politically easy for us. But only when we benchmarked ourselves across Europe could we see where we stood and what needed to be done – and that the United Kingdom was not the gold standard against which we should be judging our performance.
And it is in that context that we have been keen to work with colleagues at OECD on the development of outcomes to present to ministers of finance and to heads of government. It is very important that we take the message about health to the non-health ministers. We should recognise and promote the idea that heads of government are really health ministers in their own right.
To sum up, the six issues that we have distilled from our futures study, and that will be
identified in the Prime Minister’s letter, will probably require new thinking and priority-setting in health care by governments in the United Kingdom. That is not merely because of the new devolution of responsibility for health to its constituent countries or the impact of
globalisation on the United Kingdom. To make a real difference, the agenda will require continuing commitment from many governments in the future.
We would like to think that the Pathfinderdocument represents the first step in new thinking, making as full an assessment as possible of the factors affecting the future of health. When government starts to think about where it wants the United Kingdom to be in health and health care in 2015, we believe our documents will be seen as a way of helping them to determine the policy agenda and to set priorities. They will also ensure that for the people of the United Kingdom, the policies and the priorities are informed by an international
perspective.
Question:What does the Nuffield Trust expect in particular from this meeting?
John Wyn Owen
One of the attractions of holding this meeting with colleagues from WHO and from different parts of the world is being able to take soundings as a further step in ensuring that we are as informed as we can possibly be. We have had a very comprehensive set of responses to our Pathfinderdocument within the United Kingdom but, as we have said, we want the United Kingdom to be benchmarked internationally.
Charlotte Dargie
In terms of the project, and preparing the Pathfinderdocument, we had a United Kingdom remit. It will be very valuable for us to see if there are common themes or issues from the wider European and global perspectives. This is our first attempt at a futures study, so we want to tap into whatever experience of futures other people have. Any lessons we can learn for doing further futures work would be very helpful. Any insight coming from the wider perspective that you bring would help us discover what we have got right and what we have got wrong.
Pam Garside
Now that we have made a scan of the sectors, we want to go into much more detail in certain areas in the next two years. One area to look at will be benchmarking, including the sources of data and how they can be developed over time. Anything on this front that we can distil out of the discussions in this meeting, to legitimise our work in an international context, would be very valuable.
The British government Foresight programme
Tim Willis
Health care is one sectoral panel of the whole Foresight programme undertaken by the British government. Foresight is not new. It was established in 1993 when the government produced its science and technology White Paper Realising our potential. Foresight is just one
mechanism through which the British government derives policy and actions to accelerate the uptake of new technologies. That is why it is managed by the Office of Science and
Technology, which is currently part of the Department of Trade and Industry. Foresight looks across all government departments that are covered by the Trans-departmental Science and Technology Group of the Office of Science and Technology.
We are currently in the second round of Foresight. We are using scenario planning, horizon scanning and other tools to establish a vision of the United Kingdom in the year 2020 in various sectors. This is for the use of industry (especially small- and medium-sized
enterprises), for people in other government departments such as the Department of Health, for the voluntary sector, and for anybody else who wants to use the Foresight process to make themselves more competitive.
There will be many outputs highlighting threats, bottlenecks and opportunities, with
recommendations to avoid, accelerate or make the most of them, together with potential needs for skills and education, and implications for sustainable development. We believe that
creating a vision of the future together, with people signed up to those visions and making and adopting their own recommendations, will add to the competitive advantage of business. It will enhance the quality of life for the citizens of the United Kingdom.
The output of our programme will be visions for the year 2020, but the purpose is to guide today’s decision-makers. We make recommendations on how to be ready for the future now in the United Kingdom. We are preparing reports and scenarios to be ready in November 2000 but, just as important, we want to establish a culture of Foresight thinking in business, in government, in the voluntary sector, in all sectors in the United Kingdom. So for us, the process and the involvement of everybody is as important as the outputs.
This is one important respect in which this round of Foresight differs from the previous exercise. It is very much engaged with the social as well as the technology dimension. We have a huge number of stakeholders and a very wide-ranging list of participants in our panels, task forces and associated activities, as well as the broad government involvement.
We use intermediaries – trade and other associations – to multiply our efforts and as a conduit for our outputs. In the health care sector we are bringing together clinicians, researchers, health managers, trade unions, the voluntary sector and charities to talk and share their visions of the future together.
The previous round was criticised for having academics and the business sector together, picking out the winning technologies. Now, by widening the participation, by bringing in all other sectors and young people as well and formalising the participation of other government departments, we can share the vision together. We can be more inclusive. We also include implementation, dissemination of outputs and recommendations, in the hope that those who are involved now will also be acting on these aspects.
Ten sectors are being taken through the Foresight process. We have a panel for each sector, and we maintain an ongoing dialogue. So when I talk about our health care Foresight, it is being done in an integrated fashion with other panels covering a number of different sectors linked with it in some way. We could cite the future of chemicals, pharmaceuticals, defence, financial services and the funding of health care systems, information technology and its impact on the health care system, retail health care, and others.
When this Foresight round was planned, it was felt that there were three issues that were too important to be taken forward on a sectoral basis. They would have to be taken forward on a thematic basis, because they clearly affected the United Kingdom as a whole. First, there was the demographic trend, also seen elsewhere, of the growing proportion of people aged 55 or over. Second, there is the growing need to have crime prevention take account of new technologies, products and policies. Third, there is the huge effect of manufacturing in the year 2020 in all sectors. This adds three thematic panels to the ten sectoral panels.
Also, we recognised that there would be a need for every area of the Foresight programme to make recommendations on the implications of its outputs for skills education and training in the United Kingdom and for sustainable development.
To put the health care panel in a nutshell we are looking at 2020, at how we are going to get there, at the issues that will drive us to get there (or hinder us) and at making
recommendations on action to be taken now. The health care panel is looking at how new technologies will affect the evolution of health care over the next 20 years and the
implications they will have for research. It is also looking at the public policy options.
We are identifying significant opportunities and threats in the United Kingdom. We are looking at how we can best exploit emerging technologies now, so that they are taken up and have an impact in 2020; we are not just sitting and waiting for them. We are also attempting to gain a greater understanding of technology needs in the health care sector, so that the United Kingdom can provide for its own health care technology needs.
The health care Foresight panel consists of people from large pharmaceutical companies, from academia, from the Department of Health, from nursing and from other sectors such as
venture capital. The panel has defined nine areas of priority importance to be taken forward in a task force approach. The panel is already defining and prioritising issues. Then we are going to look at the year 2020 and the issues that are driving the future, and how they will have an influence – their impact, their significance and the probability of them happening. That will s the actions we need to take forward.
We will test the robustness of those outputs in a consultation exercise next year. We have facilities for that on the Web, so that we can have inputs to the debate from anybody who has access to the Internet. We can gain commitment from the stakeholders, who we hope will take forward our recommendations.
The nine areas we are looking at are grouped under different headings. Under the “People and social” heading comes “National, European and global milieu”, which has just changed to
“International influences on health and health care”: activities outside the United Kingdom that may influence the health of the United Kingdom population, or influence health
regulations and health policies. We are focused on the United Kingdom, but we are also very aware that there is a huge influence on health and on the British health care system from outside.
Then there are the demographic aspects – the health expectations and needs of older people and people’s own emphasis on prevention and self care and on involving the public and patients in health care systems and policy. We are looking at the organisation and delivery of health care systems in the year 2020 and how they may use, exploit and protect the
information they generate and hold. In the technology aspect of health care, genomics is going to be a huge issue.
Then there is the issue of innovation, and what is hindering the rapid uptake of new
technologies in the United Kingdom. What are the roles of the research providers (such as the pharmaceutical companies and the academics) and various intermediaries in the health care system? What are the research needs of the National Health Service, and what are the regulatory issues? The last two are areas in which there will be a huge acceleration in knowledge and technology: neurosciences and transplantation.
The nine task forces are therefore the following:
●Public and patients
●International influences on health and health care
●Older people (run jointly with the aging population thematic panel)
●Organisation and delivery of health care
●Information
●Delivering the promise of the human genome
●Pharmaceuticals, biotechnology and medical devices
●Neuropsychiatric health
●Transplantation.
Finally, there is our web site, which is able to search directly every British government web site and some others. This is where our outputs will be. But it is also being used as an interactive forum, whereby anybody who has access to the Internet can look at the draft outputs as they are created and comment on them. Thus we are trying to broaden the debate still further.
Question:Whom do you see as your stakeholders?
Tim Willis
The health care panel envisaged a range of stakeholders. They were identified at the start so that we could involve them in the process itself, and most of the task forces have them on board. They include the health care providers, both the NHS and the private sector, and the suppliers to the health care sector – from small enterprises that create medical devices through to the large pharmaceutical companies. The workforce is represented on our task forces
through trade unions and professional associations. We also have the public and patients, patient groups, charities and the voluntary sector.
Question:You mentioned that you want to build a broader basis of participation, and you mentioned young people. How do you go about that?
Tim Willis
We are using schools panels; the devolved governments and administrations in the United Kingdom have their own schools panels. We are also fortunate to be in the Department of Trade and Industry, as we can work through their regional government offices. We will be going round the regions of the country, consulting on our early outputs. We welcome as many inputs as possible, which is why we are using the Web site and electronic means to widen the debate. I believe that in any futures activity you can never have too many inputs and tests of the robustness of outputs. We are interested in comparing and contrasting our work with that of others. We certainly welcome the Nuffield Trust and other futures activities. It is interesting that we are already drawing parallels with the Nuffield Trust’s work in our early outputs.
Futures in the Department of Health
Richard Walsh
We in the Department of Health are taking a very direct interest in this round of the Foresight programme. Last time it seemed to be very much driven by technology, whereas this time there are the implications for health policy and also how NHS services are delivered in the future. Thus we have a different type of engagement from what we had before, and hopefully that will mean that the recommendations are more relevant to what policy-makers think is important.
I think this illustrates a tension between the Foresight programme and our activity in the Department of Health. The Department of Health is unique among government departments in this country, being managerially responsible for the NHS, which employs one million people, and also responsible for the regulation of social services or social care organisations. This means that we have an interest in technological innovation or new products, not merely to ensure that those new products are put on the market or that the company manufacturing them is successful, but as an actual customer for those products.
We have an interest in those products being effective and cost-effective, and that is now coming to the fore with the creation by the government of the National Institute of Clinical Excellence and the Commission for Health Improvement. So while we are signed up to the objectives of the Foresight programme, our particular perspective needs to be taken into account. We shall have to see how that works out as the groups progress and produce their reports.
The Department of Health has carried out a futures programme for a number of years. We were the first British government social policy department to use scenario planning, as it had been developed by Shell. We have used it in different policy settings in a joint collaborative exercise with the pharmaceutical industry and a number of other government departments.
We have also used it for workforce planning and capital planning for hospital building.
Another methodology used in the Department over the last ten years is simulation, to see how policy developments will evolve in the future.
We now have experience of these techniques, both in terms of running them and of the implications, and there are difficulties in using them. In scenario planning you develop different challenging scenarios as possibilities, in order to explore the implications, but we do not have a political or media environment that understands that purpose.
People take scenarios to be predictions, so a scenario in which the NHS became privatised would create a huge newspaper stir. In the time of the previous government, a simulation exercise suggesting that the NHS internal market established by the government would collapse was not exactly what the Minister at that time wanted to hear! So there are real handling problems in the use of these techniques.
One lesson we have learned is that a high proportion of the gain from using futures in planning is the involvement of people themselves, the involvement of stakeholders. They are very effective in getting shared ownership, getting people’s agendas on the table in a non- threatening environment and then getting them to think “what if”, in a way that they would not normally do.
So part of my role, as head of strategic planning, is to get that kind of thinking much more commonly accepted in the policy arena. Policy-makers working for government ministers are so often responding to immediate requirements from ministers or political imperatives that they do not think two years ahead, never mind five or ten years ahead. That is what we want to change. These processes are very good at getting people to think in different ways.
My next point is on modernisation. In the past, government departments have tended to operate separately. Current thinking is that we should act in a more coherent way like the recently established Social Exclusion Unit. The way in which we are collaborating on the Foresight programme shows how important that is seen to be.
It is also important that we work with people outside government. That includes participating in meetings like this. I welcomed the opportunity to comment on the Nuffield Trust’s work, which we have done. I hope that that this contact will have benefits both for government and for independent trusts and charities. In our perspective we will be less insular and inward- looking, and bodies such as the Nuffield Trust or WHO will gain in the sense that we will involve policy-makers from central government in the development of their programmes, rather than simply presenting policy-makers with the results of a piece of work. That relates to the point I made about ownership too; there will be a greater chance that recommendations will actually be taken forward.
Ron Zimmern
I would like to ask about another methodology. In the Nuffield Trust’s genetics project we are using both scenario planning and simulation. But there is the potential of soft systems modelling to see whether policy in one arena might interact with other policy arenas that we have been looking at. I wondered what experience you might have had in that as a
methodology.
Richard Walsh
I know of it and I recognise its importance, particularly when working with large groups of people, where the interactions between all the different areas are so complex. Others in the Department have been working with that process, but I have not used it myself. There is another process that we are looking at called “hyper-game analysis”. It was used in Bosnia in conflict resolution. We are thinking about using it in looking at primary care trusts, the new and most local-level bodies providing and commissioning services, and how they will develop in the future.
H
EALTH21 – a future-oriented policy framework for Europe
Herbert Zöllner
If we go back 25 years or more we find that WHO was then very task-oriented. It followed a
“bush doctoring” principle. The doctors went into the bush and did good things. However, unfortunately, as soon as they came back out of the bush, things went back to the original state. WHO really did not have impact in the countries. So something new was needed. Our then new Director-General, Halfdan Mahler, said it was more longer-term thinking, and some sense of context rather than the separate “vertical” technical programmes that we then had.
Mahler had also become very sceptical, cynical even, about interpreting WHO’s constitutional concept of health literally and out of context. Such perfect health – not only the absence of disease and infirmity but a complete sense of social, physical and mental wellbeing – was perhaps at the most enjoyed by some people some of the time during their lifespan. In practical terms it was surely a case of the best being the enemy of the good, because if you only promoted the ideal then action would not come forth.
So in reaction to that he facilitated the vision of health for all as WHO’s overarching policy, where equity was put in the forefront. And equity is just as important now as it was then. As one clear example, between western Europe and the countries of central and eastern Europe (CCEE) we have a seven-year difference in life expectancy. And then, going further east to the 12 so-called newly independent states (NIS) of the former Soviet Union you have a further seven years’ difference in life expectancy between the CCEE and NIS. You can find similar magnitudes of differences within countries. Equity in health is still an important goal.
Under Mahler’s leadership health itself became redefined, in the sense that the policy objective was conceived as functional health – that all people should be able to enjoy a level of health, or a health status, that allowed them to participate in normal life. The phrase used in the World Health Assembly “health for all” resolution in 1977 (WHA 30.43) was that of enabling people to lead “a socially and economically productive life”.
Informally, another phrase came into use later, that of a “satisfying and fulfilling life”. Some people had problems with “economically productive”, which they assumed (incorrectly) to mean participating in the labour market, which would never cover everyone. The true meaning was to enable people to participate in normal life. Mahler was very eloquent in interpreting this concept and applying it to every stage of life, not just to the young or physically fit.
We should also remember that in the late 1970s it was a marvellously rousing slogan, not just to say health for all but health for all by the year 2000. It was about a generation away. It looked so far away that it made sense to believe that you had time to really change things; you could rise above the immediate obstacles of life. And that is what the year 2000 meant at the start of the health for all movement.
Now that the year 2000 is upon us, and we are reminded by our detractors how much unfinished business there is, I must make the point quite clear that invoking the year 2000 was in a sense only a tactic. Health for all, both as a concept and as a philosophy, is a continuing policy.
Overall we have reason to be encouraged by the growth of the health for all movement in Europe. But I must say we had a struggle because at first not all of our Member States were fully with us. I remember delegates of the German Democratic Republic arguing confidently – or so it seemed to me – that they already had health for all: it was in their Constitution.
Another country, although it was one of the less developed in the Region, asked impatiently why one should wait for the year 2000. Yet others (actually among the most developed) thought they should be realistic and argued that the year 2000 would not be feasible but they would possibly achieve it by 2020 or, if they hit problems, 2030.
Some countries were almost overtly negative, perhaps in response to the medical lobby, which looked on health for all with great suspicion, seeing it as an attack on medical practice.
So we had quite different mindsets that we had to deal with. But in due course the health for all idea was taken seriously in the Regional Committee, and a European health for all strategy was agreed in 1980. This was elaborated in 1984 into a set of health for all targets to be achieved by the year 2000.
Some of these targets, although serious in intent, were essentially statements of political aspiration. But most were focused on reducing particular health problems, creating the conditions for health improvements, and getting essential machinery in place to pursue the health targets. In 1991 we reviewed and revised them, but kept the same time horizon of 2000.
In 1998 we produced our present version, HEALTH21 – health for all for the 21st century.
Preparing the policy documents to present to our Member States involved setting up meetings that served the purpose of sensing the future, although it was not until 1990 that we held a meeting that we labelled “futures”. Our experience since then is summarised in our paper The use of futures in European health for all policy development, which has been prepared for this meeting.
Our motive was in our recognition that health futures have to be explored, and that we needed a process of creating policy jointly with the stakeholders, which we would do by taking stock and looking forward and around. We sensed that futures could be a natural entry point for us to say to our Member States – in effect if not in actual words – let’s explore how to develop health policies, how to think about the future.
We also decided that we had to explore not so much the technical issues inside the health sector but rather the likely future environment for the health sector. That meant geopolitics, the macro-economy, ecology, broader technological developments, and social, demographic and epidemiological trends that might impact on health and health care. We later picked up on a number of issues in health care itself: first services for the elderly and then the restructuring issues of so-called health care reform, as well as the re-emergence of public health as a policy focus and the role of health systems research.
At one point we presented a draft with our assessment of some of the macro trends and their implications. Our Member States said that we were much too pessimistic and told us to revise the text. This we did, and we came out with some diplomatic mishmash. Later we submitted the new text to them. Of course, they said we should have written it more realistically! That seems to echo what we heard from Richard Walsh about the difficulties he has experienced in his own ministry.
As a United Nations organisation we have always been very clear that health for all and particular health policies have to do not just with technological developments but also with values. We were quite firm that the values could not change. We might modify if necessary some of the operating principles we adopted in giving effect to or applying the values, but not change the original values. That means, for example, that if good health is a value – something that is valued – we should place an emphasis on health outcome. Things done for health should show benefits in terms of health.
In 1998 we went further and said this should not only apply to those actions in society that explicitly or expressly have a health purpose; all action should also be looked into to see if it had implications in terms of health, that is health as a consequence.
We have been quite clear about the ethical foundations of health development and of the role of WHO itself in speaking out, with a moral but politically neutral voice, on what we saw as happening or not happening. We have pressed the international community on the need to reduce health inequities, those indefensible differences between and within countries, and to strengthen international solidarity. Morally, it is a scandal that there is this seven-year gap in life expectancy between western and eastern Europe and between the east and the far east of the Region.
Then it has to be made clear that the health sector (and WHO itself) cannot go it alone.
Health ministers definitely cannot, so therefore the need at every level is for partnership, just as previous speakers have already stressed in speaking about United Kingdom developments.
Now, fortunately, our Member States are of the same mind. The adoption of HEALTH21 by the Regional Committee is evidence that the covenant, so to speak, has been renewed. There have also been very strongly worded resolutions at the World Health Assembly, and in our Regional Committee, in which Member States pledged what they would do. Member States have said quite clearly not only what they would do, but also what they expected from the Secretariat.
I have already mentioned the place of targets in developing the European health for all policy.
The Regional Director, Jo Asvall, argued strongly that setting targets and monitoring progress were essential for policy development and implementation. However, these are also two areas where we have been criticised most by Member States. Some have asked us politely, but in effect, “Why don’t you just present your paper and then leave us in peace?” Others say,
“Rather than trying to push specific targets on us, just set up an information system. And besides, how do you define those targets – what evidence do you have to support them?”
In fact, we have made sure that for each one of the targets there is at least one country that has already achieved it; and we consider that what has actually happened has a strong chance of happening again. We have also made it quite clear that the targets will not happen
automatically, but only if a deliberate effort is made.
We have also changed our tactics, because in 1984 and again in 1991 the targets themselves were the organising principle. So as you worked through the document you went from one target to the next target to the next target, until you reached target 38. The underlying strategic coherence, which was certainly there, was not all that clear to someone reading the text.
This time we have put the strategies up front and then presented the targets as some of the sensitive indicators of what should happen in order to make progress towards health for all.
We also have an information system in place, which at least makes it possible to question what progress is being made in the different areas of health for all.
What is really needed is a new ethos of health. You all know the finance ministry ethos. It is the dominant ethos in virtually all countries; it has even infected the east of our Region. The finance minister says “budget deficit” and everybody jumps. The ethos of social and health deficits you do not hear. You do not see any news reports that the social deficit has increased because of a reported increase in the number of single mothers, or an increase in the number of registered unemployed.
